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Fire Drills in ASC Located in a Shared MOB

by Brad Keyes, CHSP, on Dec 13, 2019 12:00:09 AM

Q: We have 13 off-site Ambulatory Surgery Centers and some are in stand-alone buildings where they are the only occupant and some are in high rise Medical Office Buildings (MOB). For quarterly fire drills, are we to have staff activate the building general fire alarm system for every drill? For the stand alone sites I do not see a problem with this, but for the others in MOBs we do not own where 90% of other tenants are business occupancies, cancer patients, rehab centers, etc. Are we not creating unnecessary stress by dumping the building four times a year, which is exactly what would happen if we pulled the pull station in a MOB? I reached out to the supervisor of the surveyor that cited us, but wanted to gain another perspective.

A: The surveyor was correct in citing you for not activating the fire alarm system during a fire drill. It is a key requirement that provides staff with knowledge and understanding what an actual fire alarm sounds and looks like.

I do see and understand your dilemma in those MOB’s where your organization is not the only entity in the building. But haven’t you discussed this issue with your landlord yet? There are ways to re-program the fire alarm occupant notification system (i.e. strobes, horns, chimes, etc.) to activate only in your area. Yes. It may cost some funds to do so, but that is part of the cost of doing business in a building that is shared with other entities.

Also, have you discussed the option of conducting building-wide fire drills with the other occupants? Since you’re an ASC you must do quarterly fire drills and the other entities may be business occupancies which only require annual fire drills. But if you scheduled the drills at a time when it is least likely to disrupt operations of everyone, then the other entities may be more accepting of your situation.

The bottom line: You must activate the fire alarm system when conducting a fire drill. Discuss this challenge with the other tenants and see if they are willing to accommodate you at various times (i.e. early in the day or late in the afternoon). If not, then invest in making the fire alarm system activate only in your area during a fire drill.

You do have options…

Topics:Ambulatory Care OccupancyLife Safety CodeFire Drills

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